As HIV diagnoses rates keep on climbing locally, reaching one of the highest in the EU, the free government provision of prophylactic (preventative) HIV medication could be a local game-changer, Marc Buhagiar, the president of Checkpoint Malta, an HIV awareness NGO, said.

"HIV diagnoses in Malta keep rising with the rate being one of the highest in Europe. A main reason for this is the lack of provision of free PrEP (Pre-Exposure Prophylaxis) and PEP (Post-Exposure Prophylaxis) medications. In fact, if you see countries which have PrEP for free the HIV diagnoses have plummeted due to PrEP being 99% effective in preventing HIV," Buhagiar told The Malta Independent on Sunday.

For him, such a measure is a "no-brainer" particularly following electoral pledges from both the Nationalist and Labour parties. There have been no "stand-alone" allocations in the 2025 Budget, he said. While an allocation to the Ministry of Health was made for free medication, "we don't know what medications they are referring to. It could be for heart disease, it could be for cholesterol...it's an umbrella term".

"Ultimately, a person living with HIV has to be on lifelong treatment and that costs so much more. So economically speaking, it's ridiculous. While prevention is always better than cure, in this case it's cheaper as well. This is why these medications should be free."

HIV (human immunodeficiency virus) attacks and destroys the human body's natural immunity from infection. If left untreated, HIV makes it difficult for the body to fight off infections, and can lead to the condition known as Aids (acquired immune deficiency syndrome). World Aids Day is being commemorated today.

HIV is chiefly transferred via blood, semen and breast milk, among other bodily fluids. While in the past HIV was akin to a terminal illness, today a number of medications are available and actively administered, giving it a status closer to a chronic illness with people living with HIV leading long, healthy lives with an unaffected life expectancy. 

Buhagiar said that Checkpoint Malta was set up alongside and simultaneously as HIV Malta, another NGO, in a time when no one was talking about sexual health or HIV. He said that the fact that both were set up at the same time showed a "realisation" for the need to start a conversation on HIV.

"We wanted to demystify HIV, since most people still think of the virus as something from the 80s and something that will kill you, which is not the case anymore," Buhagiar said. He added that, with recent advances in medicine, not only can one's immune system be saved and preserved, but a person can reach the status of "untransmittable", that is cannot transmit the virus to other sexual partners. 

Buhagiar said that the physical state of "undetectable means untransmittable" (promoted in an awareness campaign as U=U) through modern medicine, which was well-researched, confirmed and adopted abroad, took much longer to be officially recognised in Malta.

Buhagiar recalled a highly distressing time in 2020 when people living with HIV in Malta suffered a severe shortage of the essential prescription. "Basically we had a national shortage during the height of the Covid-19 pandemic at the same time as Brexit. It was awful. It was a horrible time because everyone's safety net was just taken away from them."

From the government's side, Buhagiar said that the public health sector took a back seat as they had no medication to dispense, resulting in many people living with HIV "going into a tailspin". But Checkpoint Malta rose to the occasion, bending the rules in the process. "We went into 'Robin Hood mode', but it was either that or people couldn't access medication. People from the community came together in the time of crisis and it was beautiful. Basically, people living with HIV came together to give their surplus medication to Checkpoint Malta. So if someone would ask for a type of medication, we would hand it out. I even had people coming outside my house. And all this was so that their treatment plan would not be interrupted as much as possible."

Buhagiar noted that following the shortage, Maltese public health updated its treatment plans going from its outdated daily regimen of six or more pills, to the internationally-standard pill-a-day regimen. That said, he pointed out that Malta still falls behind the latest HIV medications with the introduction of injectable medication abroad that is yet to reach Malta. 

When it comes to EU Nationals and Third Country Nationals (TCNs) living with HIV in Malta, Buhagiar said they must show payslips for access to the medication and other treatment as proof that they are paying national insurance. He pointed out that problems begin to arise while TCNs are waiting for their documents from Identità "which everyone knows are taking time".

Buhagiar explained that if these individuals' medication runs out as they are waiting, they would have to buy it themselves out of pocket at a high cost. Consequently, they would panic as their supplies dwindle and struggle to get their hands on the necessary, expensive medication or have someone send a supply from their home country, he said. 

While missing a dose or two is "not a tragedy", Buhagiar said that the problem is the more doses one misses, the greater the chance of the viral load becoming detectable again. "Once your viral load becomes detectable again then the virus starts replicating, attacking the immune system again and running its natural course, for which there's no cure yet." For this reason, he believes "anyone currently residing in Malta, whether they have their paperwork done or not, should be eligible for free treatment. Why? Firstly, you keep those people undetectable and so, safe, with their immune system protected and the virus kept under control. Additionally, you also keep the community at large protected because if they have sex, then there's no risk of transmission". 

When it comes to an interim insurance for TCNs living with HIV until they get their documents in order, Buhagiar raised concerns with the Health Ministry multiple times over months but, "I haven't received a straight answer yet". He explained: "Insurance is very strict about pre-existing conditions, HIV especially. It's certainly not going to cover HIV costs since it is a pre-existing condition, in the same way that someone with cancer wouldn't get insurance." For him the bottom line is, "how are these people going to access treatment with this insurance policy? I'm very worried about it because I think people are just going to go without treatment because of it. It's a big issue when there's no clear indication on how to go forward".

Buhagiar acknowledged the concerns and grievances of the public who would view it as an added burden to their taxes. He sees it differently. "You can see it from the perspective that if these few people are protected and healthy with their viral load under control, then everyone is healthy and safe as a result. And this is why I keep reiterating the call to treat everyone regardless of their residency status."

As things stand, Buhagiar said that those needing PEP, following a potential infection, must refer to the GU Clinic or the Emergency Department; if the GU Clinic is closed, at a cost of an eye-watering €700 within 72 hours. "The price is a complete barrier for the people who need it the most, such as sexually active students. Plus, if you're from a lower earning bracket, there's no way you can access it." When asked if there was a particular reason why the government was dragging its feet when it comes to a medication that can completely avoid a life-long illness, he said: "We keep pressuring the government to make the medication [including PrEP] free. Unless they actually put their money where their mouth is, we're going to keep seeing our diagnoses going up."

When it comes to severe misconceptions of HIV, Buhagiar said that "the current perception is that HIV is a 'gay man's disease'. It's not. And it's also unfair to say since globally, most people living with HIV are women". He acknowledged that queer men are a prominent risk group. He, however, stressed: "I still don't think that they should be the only focus." In sum, "women are left out of the equation or at least if they are in the equation they aren't really that factored into it", he said. 

Buhagiar went further than sexism within the HIV nexus. "We have to move away from HIV being a 'gay disease'. That perception does much more harm than good." He acknowledged the intimate interlinking of HIV and the LGBT+ community, "obviously the LGBT+ community feels it more because of what happened in the Aids pandemic, and they were mostly the ones dying".

On the other hand, he explained: "I find that linking the LGBT+ community so much with HIV is a disservice, not only to the LGBT+ community itself, but to the community in general. That mentality basically means, 'since I'm straight, yet sexually active, I don't need to get tested for HIV because it's not my virus so I'm not at risk of it'. That is a very flawed way of approaching it because it can affect anyone." He added: "Everyone should be tested really, especially if they're sexually active. That's why I think that this mentality needs to change."

"There needs to be more testing awareness. I think more people need to get tested. You shouldn't wait for symptoms to develop. In fact, some people living with HIV never develop any symptoms, but symptoms or not, they'll have the same thing. So my call is always if you're sexually-active, get tested regularly. It's part and parcel and protects you and your sexual partners," Buhagiar said. On the scale of Maltese public health he said: "I think Malta should follow the UK's lead in opt-out testing. This means if you're admitted to hospital and you need blood work done, an HIV test will automatically be done, though you'd have the right to opt out." 

Buhagiar acknowledged however that testing isn't always easy. "I have spoken to people who are afraid to get tested because it might result in a positive. And I understand the fear, I really do, because it's only natural. But at the same time, if you don't get tested, you can't take action." He elaborated that the fear is seeing the result "on paper" however he stressed that at the end of the day, "if you know, you can do something about it, you can go on treatment, and therefore you can protect yourself, and you can protect your sexual partners. So, it's always better to know than not to know".

Additionally, Buhagiar pointed to the fact that "early diagnosis is always better because there are fewer complications. If you detect HIV in an early stage then the virus wouldn't have developed enough for it to damage your immune system so much". Furthermore, he said that in 2023 there were two cases of Aids which he explained, "at that point your immune system has basically plummeted, giving room to health complications and opportunistic infections. It's very worrying to still have people reaching that point in this day and age."

Activists from a coalition of NGOs, including Checkpoint Malta, are set to gather outside Castille, Valletta today, Sunday, 1 December at 11am for a rally on World Aids Day, demanding HIV-related electoral promises, policy changes and an end to stigma.